Hemiplegic Foot

in Children and Teenagers:

When to consider surgery?

Antoine de Gheldere, MD

Consultant in Children’s Orthopaedics and Trauma

GNCH – Royal Victoria Infirmary

Newcastle upon Tyne, UK

Peacocks meeting, Saturday 9th January 2016

3 principles to remember

1. Nobody can cure Hemiplegia (CP)

2. A “neurological deformity” doesn’t get

better with the growth

3. The foot is in continuity with the leg

Common Gait Patterns

Motor Cortex Lesion

Motor Cortex Lesion

Common Hemiplegic

• Walking (GMFCS 1 or 2)

• Distal disorder (hand and foot/ankle)

• Weak ankle extensors (dorsal flexion)

• GCS/S increased tone

Natural History

Worsen without treatment

Worsen without treatment

Natural History

EQUINUS (Triceps tone ++)

Plano-valgus (Talus subluxation)

Cavovarus (TP/TA tone ++)

Reasons for referral

• Gait difficulty: foot – knee – hip – trunk

• Foot pain/discomfort

– Medial or Lateral

– Fixed deformity

– Bunion (teenagers)

• Instability (teenagers)

Clinical Assessment (1)

1st Question: How is the foot position?

• Static

• Dynamic

2nd Question: How many joints affected?

• Knee, hip, trunk, (upper limb)

• Dynamic deformity (spasticity)

• Video recording or gait analysis

Clinical Assessment (2)

3rd Question: Active foot control?

• Selectivity

• Foot “balance”

• Weak agonist vs. antagonist contracture

Clinical Assessment (3)

Active force

Spasticity

Contracture

• Physiotherapy

• Orthotic

• Botulinum toxin

• Serial cast

…

• Surgery

Treatment options

Surgical Indications

• Fixed deformity

• Uncomfortable flexible

deformity

• Compensation deformity

• Gait deterioration

“Do not wait the end of the growth”

Type of Foot Deformity

Equinus: 35%

Cavovarus: 35%

Planus: 12%

Valgus: 6%

Bunion: 12%

Planus Valgus

Equinus Cavovarus

Equinus

Normal initial contact

- Foot in neutral position

- 30 degrees with ground

No more Achilles lengthening!

Normal foot

1st Rocker = Heel

Ex moment = PF

Tib Ant

Eccentric

Absorb impact

2nd Rocker = Ankle

Ex moment = DF

Soleus

Eccentric

Ankle trunk forward

3rd Rocker = Toes

Ex moment = DF

GCN

Concentric

Propulsion

Cavovarus

• Triceps (GCN/S) tone ++ or contracture ?

• Weak DF: TA? EDL? EHL?

• TA or TP ?

• Weak Peronei ?

E (girl), 10yo.

Cavovarus deformity

(+supination)

+5 years

Split TB to PB

GCN lengthening

Calcaneus VgO

M1 closing wedge

H (girl), 8yo.

Cavovarus deformity

(+ADD)

+4 years

Split TP to PB

Calcaneum VgO

C1 open wedge

Planovalgus

MILD PV

• Similar to idiopathic

SEVER PV

• Similar to diplegic

• Work on the bone!

J (boy), 9yo.

Planus deformity (mild)

+3 years

Calcaneum open wedge

GCN lengthening

TP shorthening

TN joint repair

J (boy), 9yo.

Planus deformity

External rotation

Genu valgum

+2 years

AA medial derot. O.

Calcaneus double O.

GCN lengthening

PB lengthening

TP shortening

TN capsule repair

Teenagers Hemiplegic Foot

Problem No.1: Doesn’t like splints

• Stretching self-teaching (gym)

• Shoe compensation

– “high heel”

– Boots

Teenagers Hemiplegic Foot

Problem No.2: Ankle instability

• Bardot procedure if:

– Reasonable TA

– Flexible deformity

– “Tenodesis”

Bunion – Hallux Valgus

• More frequent with planovalus foot

• Osteotomy and ADH release

• Aim M1P1 at 0

• Fusion only if (symptomatic) failure

D (boy), 12yo.

Hallux Valgus (mild)

+3 years

M1 osteotomy

P1 osteotomy

PM1 lat. Hemi-epiphysiodesis

Take Home Message

• Conservative treatment first

• Don’t wait end of growth for surgery

• Understand the deformity

• Avoid fusion

• Osteotomy(ies) and soft tissues

Thank you

Antoine.deGheldere@nuth.nhs.uk

Website: http://orthopaeds.com